"That is happiness; to be disolved into something complete and great. When it comes to one, it comes as naturally as sleep." - Willa Cather

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Wednesday, 22 September 2010

Running longer than a marathon is unhealthy... says Jacob Fuglsang

I am writing this in response to an article written for Politiken, Denmark's major newspaper, in the Sunday September 19th editon. The article is called "På kanten af kroppens formåen" -"On the edge of our body's capability." I want to discuss what Jacob says the dangers are in ultras and where I disagree - and where I think there are additional dangers he doesn't mention.

"If we start with the question of health: It isn't healthy. Participants know it and scientists are in agreement"

The "it" he is referring to is racing a longer distance than a marathon. I will first caution Jacob that he should be more judicious with his generalisations. There is no reason to believe that hopping up to a 50k distance is more dangerous than a marathon. It depends on how one runs it. And it is dangerous to start an article saying all scientists agree when there is discussion of many different types of dangers and studies with meaningful evidence are lacking.

But what is it he and the expert, Michael Voigt, he interviews say are dangerous about these long races?

1. Kidney failure. He explains well that during races there is constant small bleeding in our muscles and, as a results, proteins are released into our blood which the kidneys have trouble clearing. This can lead to kidney failure.

My response: this is exactly true, but it happens every time we exercise and it is also part of the process of building new muscle. Muscle breaks down and is built up again at some point, but the waste products need to be eliminated. If one is dehydrated, one is always at risk of clogging the kidneys with the breakdown proteins (myoglobin), regardless of how far one runs. If one stays adequately hydrated during an ultra, one will not have kidney failure. It is really that simple.

An example from my own life (where I did it wrong). When I was doing a vascular surgery rotation, I was afraid of having to pee during the 7-8 hour surgeries, so I basically stopped drinking. After one of those surgeries, I went on an hour run and when I got home, I urinated something that resembled cola. I went to the ER and got IV fluid (now I would just drink a lot of water) and everything was ok. Luckily I got hydrated in time to avoid kidney damage from the proteins sitting there, stuck in the tubules (the real damage comes - and possible kidney failure - if they're not cleared out fairly quickly. I say "fairly" because it depends how much protein you've got stuck in there and what your glomerular filtration rate is to begin with).

I would say that kidney failure is not something that is in of it self dangerous in ultras, but is a running danger one should be aware of. The best way to avoid it in a race, especially when it is hot, is to drink lots of sports drink which is isotonic with our intravascular fluids (I'm talking veins here). Most sports drinks are close enough to this that they work. And they will also help one to avoid the other major risk of overhydration from water alone - hyponatremia. (One doesn't become low on salt unless one is sweating, so if you've stopped exercising, plain water is fine).

2. Fracture.

Agreed, obviously. But again, it is not a danger inherent to ultras. I would say one is more likely to break a bone by going out downhill skiing than running an ultra. I guess I would not even mention it as a specific risk. But then again, considering Steve Q's track record, it may be a particular risk to certain people.

3. Avoid painkillers.

Here Jacob simply didn't go into any sort of detail other than to say pain killers increase the risk of kidney failure. But there are different types of painkillers with different dangers.

Ibuprofen/Ibupren - this is the prototypical NSAID - decreases kidney function by inhibiting with the body's formation of prostaglandins, which are protective to the kidneys and stomach among other things. The same goes for all other NSAIDS. They should be avoided in races. I used to feel differently, but I read a very well-written, well-researched article in the New York Times, which changed my mind. They decrease performance and are potentially dangerous for our kidneys (and cause stomach upset - but that is a minor consideration when taken short term).

Tylenol - if you take 4 grams or less (that is 8 tablets) a day and you don't have a liver disease, there is no danger. The only problem is, it doesn't work for muscle pain. But if you have a headache, feel free to indulge. It is not a risky medication unless you overdose.

Opioids - no matter where you live, you need a prescription to get these and you can't even drive a car when taking them since they make you so drowsy. They also make you nauseated. They work for pain, but would be overall a huge detriment in an ultra due to the side effects. If you have pain that bad, just don't run.

Immunosuppressive steroids - ex. prednisone (like opioids banned from races and by prescription only) - these work for swelling and long term for certain types of pain. Some ultra runners have taken them to keep going days in a row. I actually do believe they are effective at reducing pain due to swelling. I agree, however, they should be banned from all sporting events as they prevent proper recovery and are quite dangerous to take long term. Short term, they present the same dangers as Ibuprofen, but even more pronounced, and can cause a psychotic-type reaction in certain people.

4. But the brain does fine.

Jacob discusses here how running benefits the brain. It is true that it is good for depression and mood and also for increasing one's pain threshold for the rest of the day (though as for ultras, I usually feel I have MORE pain afterwards :)), but I believe long-distance runs (marathons included) can also be dangerous for the brain. And this is not something I have any research to back up.

1-2 days after a very challenging athletic event (the longer and more physically exerting, the more profound it is), I have trouble thinking as clearly and acting as quickly as usual. Especially when I was working with patients daily in ophthalmology, I found I had a lot of trouble examining them. For anyone who works in a job where another's life/vision is potentially in danger, I would highly recommend taking at least one day off after a marathon/ultra/ironman to avoid potential harm to another. Exactly what this is caused by, I am uncertain, but believe it is shunting of essential nutrients away from the brain and to the recovering large muscle groups.

Psychiatrically, ultras are also dangerous because of the level of commitment they require to perform well in them. One may find oneself abandoning all one previously perceived as important (relationships, dedication to work, etc.) in order to find time to achieve the goal of a certain ultra - and that is probably the biggest danger of all. Trust me, I know. Plus the attitude of wanting to finish at all costs is dangerous for obvious reasons.

Finally, the overall statement that ultras are unhealthy, I think is false. I do not think there is evidence to support this either. I think ultras have risks, but I don't think that a few days or a few weeks after an ultra that one is less healthy. And I think training the heart and muscles to achieve that sort of endurance is healthy, at least physically.

That's all I have to say in response to Jacob.

If that was boring, here are some pictures from our tri club championship last weekend. The most notable part of the tri was the water being about 13 degrees C - I'm not going to look it up, but am wagering that is around 55 degrees F. Suprisingly, I LOVED it. Well, not the first two minutes, but after that it really was wonderful.

Our club captain, Anette.

First woman out of the water, Maria. Rikke, who beat me by less than 30 seconds. Grrrrr..... Søren, first place for the men:

Have I mentioned that I spend a lot of time dreaming at inopportune times?

Running song of the day: Driving to LA by Household Names (from Austin, for those who might live nearby :))

16 comments:

It was interesting being part of a medical research study at Western States last summer -- my BUN was really bad at Foresthill (mile 61 or so) but I felt fine -- other than my feet. The researcher who sent my results said she was glad I dropped at mile 72 since she thought I might have ended up in the hospital. I don't necessarily buy that, but do wonder whether that results in permanent damage or if I just recover or end up better off? I sort of thought maybe it wasn't super healthy, but I blame the heat not the distance :p

We seem designed to be able to sprint for at most a few hundred meters and to be able to walk for 12-15 hours a day - hunting and foraging, I suppose - it's the inbetween stuff that's risky. Prone to injury as I am, I've had as much trouble with 10K training as ultramarathons, it's just different types of stress lead to different types of injury and ultramarathons have an increased risk of accidents just because of the duration (and tiredness and running in the dark).

Running longer than a marathon is not necessarily unhealthy, but racing it is risky.

While all of this is way too scientific for me, and I run ultras because I love it emotionally (surely not because it's good for me), I have to honestly say, there is a lot about doing them (at competitive level anyway) that is not good for your body. Granted, if and when we are aware of dangers/complications, we can and should minimize them, but still those damages are absolutely unnecessary to begin with, and they still happen (as with other sports, indeed). Just like with food and diets, everything is good in moderation. There is nothing "moderate" training for and racing distances 50 miles and more (seems where the body break-down happens most). Having said that, it is not unhelathy either. It just what it is - causing unnecessary, potentialaly (key word here) hazardous conditions on ones body for the sake of mental/emotional well being. Again, most of those could be avoided/postponed/taken care of/minimized with correct approach, but 99% of us will make mistakes and will experience one of the things we might have not had we not being doing this kind of things. Now, of course, we happen to get sick and injured by living daily live as well:)

Olga, yeah it was kind of scientific, I guess - just to continue that trend, I will point out to Danni that the most likely reason your BUN was elevated was due to simple dehydration (but I couldn't know for sure without a creatinine). I have a feeling that if you measured the BUN of everyone in an ultra they'd pretty much all be elevated even if their kidneys were fine.

Steve, I entirely agree with your evolutionary spin on it. But training also counts for something and we can get our bodies quite "ready" for an ultra by training right. It also helps to know what to watch out for and how to fuel (I'm still not that great at that - actually I'm not very good at the training part either).

my two cents - it's more of a bullshit article than an interesting one. i just hate generalizations about running. i think for any distance or terrain, it's all about your own goals and your own training - if you train smart and stay healthy during your training, if you set realistic goals and race within (or just beyond) your abilities, adjusting as necessary for the conditions (heat/cold etc), and if you allow yourself proper recovery time post-race - then there is NO reason for an unhealthy outcome - physically, mentally or emotionally (apart from the usual low feeling after a big event that I suffer from at least - but we all know the cure for that!). The problem is that only a small percentage of people follow this path... I sometimes do for definitely not always... you have to allow for spontaneity in this sport!

In the article, Jacob Fuglsang essentially describes rhabdomyolysis ("rhabdo", if you're cool). Most ultrarunners are aware of rhabdo. There is a spectrum between mild dehydration and severe rhabdo needing dialysis. Most cases of rhabdo resolve with no other treatment than fluids.

However... does rhabdo cause permanent kidney damage? Certainly, kidney cells die in the process, but I wasn't sure if kidney cells regenerate or what they do. Hematologists are the smartest docs in the hospital, certainly, but sometimes they need a little help. I asked a nephrologist whether those cells that die and get peed out like casts (cola-colored urine) can regenerate.

He didn't know for sure. He thought that maybe a few % of the cells die and that they DON'T regenerate. So, theoretically, if you develop rhabdo 20 times, your kidneys have a lot of their reserve.

In healthy adults, you have so much spare function in your kidneys that you can live with just one (which is why you can donate a kidney). But as you get older, your kidneys slow down and even mild dehyration can result in kidney failure.

So rhabdo is no joke. You never know when that small percentage of kidney function may come in handy.

I've always thought the problem with rhabdo was that, after the kidney cells fail, lack of fluid keeps toxins in contact with healthy cells too long and they start dying too, creating a cascade effect. I think the amount of regeneration depends upon the degree of damage done.

But then again, I only know that at Ice Age, I was relieved when my urine went from brown to pink after drinking a gallon of water. Bloody urine? No biggie. Rhabdo had me scared, though.

Obviously Steve - I wouldn't recommend ANY of those for you as that would conflict with the most important advice of not up your routine TOO much.

I laughed when I realized that BUN meant something other than half of Danni's ass. Sorry to be crude but I was thinking it must have been really painful if it forced you to drop... then I read SLG's comments...!

This is a very cool post. I think science has still a lot to learn about endurance running. We humans used to do A LOT more of it in our ancient past than now and I believe that with proper training/nutrition/hydration we should be just fine at very extreme distances. There is a pretty decent body of research showing that long distance running helped us not only survive but also to evolve to where we are now. And then we invented agriculture... but that's another story.

Hello from Rude Skov

Photo by Stine Sophie Winckel

...

My name is Tracy. I am a physician scientist from the USA, living with my husband and two young boys in Denmark. I work as a post-doc fellow at Næstved Hospital. I have a scientific interest in vision loss, vision loss during exercise, exercise, running during pregnancy, MAF training as well as nutrition and health for athletes. I also have a love for music, physics, statistics, cycling, yoga, cross-country skiing, bla bla bal.

I was a member of Team USA at the IAU World Championships in Ultra Trail Running in 2013 in Wales. I am now training to run with Team Denmark at the IAU World Championships in Annency, France in May 2015.